| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,015 |
3,546 |
$91K |
| D1206 |
Topical application of fluoride varnish |
4,860 |
4,278 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
4,364 |
3,865 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,088 |
462 |
$41K |
| D0272 |
Bitewings - two radiographic images |
2,108 |
1,850 |
$34K |
| D1351 |
Sealant - per tooth |
1,564 |
309 |
$25K |
| D1110 |
Prophylaxis - adult |
847 |
741 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
948 |
749 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
656 |
321 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
588 |
506 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
77 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
258 |
229 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
15 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
212 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
48 |
$1K |
| D1999 |
|
937 |
646 |
$1K |
| D3120 |
|
118 |
77 |
$0.00 |
| D0603 |
|
627 |
545 |
$0.00 |
| D0330 |
Panoramic radiographic image |
26 |
24 |
$0.00 |